What does my child need: neuropsychological or psycho-educational assessment?

When choosing an evaluation for your internationally adopted child, you basically are making a choice between the three brunches of contemporary psychological services: clinical-, school-, and neuro- psychology. It is assumed that all three types of psychological services are provided by doctorate level (having either Ph.D. or Psy. D. titles after their names) licensed child psychologists.

Clinical psychologists assess and treat children with a wide variety of psychological problems, with emotional/behavioral issues in particular. They may work in hospitals, community health centers, or private practice. Although most of clinical psychologists work with a wide variety of populations and problems, some may specialize with specific population or specific disorders (e.g. attachment or post-traumatic stress disorder). They are trained in universities or professional schools of psychology and may not be well familiar with school settings. Clinical psychologists provide both assessment and treatment (psychotherapy).

School psychologists are involved in the enhancement of developmental in educational settings of a child. They assess psycho-educational abilities of the child and recommend actions to facilitate student learning and overall school functioning. They are typically trained in Schools of Education at universities and work in school systems, community-based agencies, or private practice. A few may specialize with a particular school-related problem, such as learning disability or ADHD. While specializing in educational issues, they may not be well trained in medical-based disabilities and disorders. School psychologists usually administer both norm-based psychological tests and criterion-referenced educational (achievement) tests.

Neuropsychologists represent a specialized discipline within the field of psychology that mostly focuses on cognition (the ability to think, remember, learn, etc.) under the circumstances of brain damage and organic brain disease. A neuropsychologist can administer standardized psychological and neuropsychological tests to patients in private office and hospital settings and offer various forms of cognitive rehabilitation, clinical opinion regarding the presence, scope, and treatment of cognitive disorders and behavioral disturbances as well as certain mental illnesses. A neuropsychologist is guided by knowledge of brain development, brain organization, and the effects of various forms of brain injury on development. Please note that damage to brain functioning can be due not only to physical injury, such as severe blow to the head, stroke, chemical and toxic exposures, organic brain disease, substance abuse, etc., but also can be due to non-organic trauma, such as severe deprivation, abuse, neglect, mental disorders, etc., as seen in many IA children.

All three specialists may use standardized psychological tests (SPT), observations, interviews, and different questionnaires as their major professional tools. Standardization is a clinically established procedure developed to diagnose and quantify mental conditions, expressed in certain behaviors. Resulting SPTs have clinically validated norms. Thus, a measure of deviation from established norms helps determine the severity and scope of a manifested mental condition or pathology. An SPT administered in oral, written, and tactile forms, is quantifiable and often uses standard scores and a percentage. Please note: IA children are not a part of a standardization sample in any officially published test and a psychologist must understand the limitations in using standardized tests with them. In addition to the same tests that are used by clinical and school psychologists, a neuropsychologist can administer specific neurological tests. These are also standardized, clinically-established procedures, developed to assess the severity and scope of existing cognitive/emotional impairment. Such procedures are usually administered to high-risk, seriously deficient patients, exhibiting obvious symptoms of cognitive dysfunction and impairment. A typical neuropsychological battery may include up to 8-12 specialized tests selected by an attending professional and can take several hours to complete.

The question is: when should a parent of a post-institutionalized internationally adopted child consider a neuropsychological assessment? Not every child experiencing school problems or behavior problems needs a neuropsychological assessment.
Neuropsychological assessment can help if your child:
Had a neurological condition such as hydrocephalus, cerebral palsy, epilepsy (seizures), neurofibromatosis, tuberous sclerosis, a brain tumor and other medical problems that place him/her at an increased risk of brain injury such as diabetes, respiratory problems, and certain genetic disorders.
Had a brain injury as a result of an accident, a stroke, or an infection of the brain.
Had been exposed to toxins such as lead or was exposed to alcohol prior to birth (FAS).
Had an assessment by a clinical psychologist or a school multidisciplinary team, but interventions resulting from that assessment failed to help.

There are, of course, certain situations when an attending physician may recommend or request a neuropsychological assessment in order to assist in establishing of a diagnosis, to document the current skills of your child prior to a planned medical intervention, or document his/her cognitive developmental level so that medical treatments, family expectations, and school programming can be adjusted to your the changing needs.

Another question is: will neuropsychological assessment be covered by my health insurance? Yes, a neuropsychological assessment is typically covered under medical coverage when a child is referred by a physician. Be aware that a neuropsychological assessment is usually covered if testing is conducted to establish diagnosis as the basis for medical treatment, to evaluate the functional impact of medical treatment (baseline testing), or to assist in selecting a treatment. For example, for some children, the use of medication may be the best approach when behavior problems occur, while for other children, the use of a behavior plan or psychotherapy is the best approach. Neuropsychological assessment is usually covered if your child has learning or behavior problems and has a history of brain injury, or has a current medical problem that may be affecting brain development. Many insurance plans will require a letter from your physician, indicating a medical necessity of an assessment. A medical necessity means that your the physician of your child needs additional information to help him/her provide care for the child. Please note, that most insurance plans will deny coverage for assessment used to establish an educational diagnosis (e.g. learning disability). Medical insurance carriers view this as responsibility of your school. However, the coverage will often be provided if the assessment is done to substantiate a relationship between an academic problem and some other medical problem or medical treatment.

Still another question is: how will neuropsychological assessment help my child with his/her school-related problems? There is no simple answer, unfortunately. The problem is that being skillful clinicians, many neuropsychologists may still be unfamiliar with special education procedures and the linkage between assessment and intervention in schools. They may end up with purely medical diagnoses and unrealistic and irrelevant recommendations that can be easily rejected by your school as "inappropriate". They may use instruments and procedures that are suitable for hospital settings, but are irrelevant for school settings (e.g. some projective procedures). Therefore, when hiring a neuropsychologist as an independent evaluator, parents must be sure that this person is not only qualified to perform the required evaluation, but also has training and experience needed to collaborate with school staff in developing programs and interventions for students. Ideally, a neuropsychological assessment will provide you with a description of learning strengths and weaknesses of your child and recommendations for educational program. The report should include suggestions on how to help your child to improve weak skills and how to use strong skills to compensate for the problems.

And finally, the most important matter. Regardless of a specialty of the professional working with your child, he/she needs to have experience with, be knowledgeable of, and be sensitive to the issues related to post-institutionalized internationally adopted children. If the specialist has no prior experience with these very special patients (and you have no one else to go to), at least educate this professional by providing articles to read or refer him/her to relevant websites on the Internet before the first appointment. Unfortunately, too often even good specialists in their disciplines are confused with post-institutionalized children and may either overlook or dismiss the important issues. When you bring your IA child to the office of a psychologist, the professional sees a well-groomed and nicely dressed child accompanied by somewhat nervous, but otherwise "regular" middle-class, well-educated parent(s). If the child has been living in the country over a year, his English (communicative) will be indistinguishable from his/her peers. So, in the perception of a psychologist, this is a typical family with typical issues (may be serious issues, but still "typical"). Even when the history of the child is known, it is difficult for a psychologist, who never dealt with post-institutionalized children, to change the set of mind and to re-examine the ways of assessing and interpreting the results. It is especially obvious in the assessment of developmental disabilities and issues related to language processing.